Airways Clearance
In several lung conditions such as NTM lung disease, bronchiectasis and COPD, the lungs are less able to remove phlegm or sputum. When old sputum sits in your airways, it causes inflammation and possibly further damage to your lungs. Bacteria, such as NTM, love getting into this phlegm and causing inflammation. Airways clearance helps to get this mucous out of your lungs, making it harder for the bacteria to grow there. Besides treatment with antibiotics and other medicines, chest physiotherapy can be very helpful. Here we explain what it is and how you might adopt some of the techniques.
Please bear in mind that the advice given here is very general. Ideally, your GP or consultant should refer you to a respiratory physiotherapist, when you will be given advice on chest physiotherapy personalised for you and your techniques can be reviewed.
What is chest physiotherapy?
There are many different aspects of chest physiotherapy; here we focus on two main principles. 1) chest clearance and 2) exercise.
Why is airways clearance important?
In conditions with excess sputum (phlegm) such as NTM lung infection, cystic fibrosis, bronchiectasis, primary ciliary dyskinesia and COPD; chest clearance is considered a cornerstone of treatment. It should become part of your daily routine. It is used to:
make breathing easier - excess sputum may reduce oxygenation
reduce the number and frequency of chest infections
prevent further damage to the lungs
prevent excessive coughing which may have an impact on quality of life
help clear bacteria in the lungs alongside antibiotic treatments.
How often should I clear my chest?
This varies from person to person, at the very least it should be completed daily, ideally twice per day. During a chest infection you may need to clear your chest more frequently. Many people find morning and evening best. This allows clearance from the build-up of sputum overnight and to prevent excessive coughing through the day. Clearance in the evening can prevent sleep disturbance due to coughing.
How can I make it easier to clear my chest?
Make sure your airways are open enough.
Narrow airways will make it difficult to clear your chest. If you have been prescribed short acting (reliever) inhalers or nebulisers e.g. salbutamol or ipratropium take these 10-15 minutes before you try to clear your chest.
Make sure you are well hydrated.
Inadequate hydration will make your sputum thick, sticky and harder to clear. NHS guidance on how much fluid to drink per day is 6-8 glasses which is 1.2L or 2.5 pints. Try to avoid excessive amounts of caffeinated, carbonated or alcoholic drinks as these can have a dehydrating effect on you. You will need extra fluid in hot weather and during a chest infection as you may lose fluid through sweat. If you are drinking sufficient fluid and your sputum remains thick then talk to your GP or respiratory consultant as there are medications which may help to thin your sputum to aid clearance.
Hygiene
When you have coughed up some sputum it is important not to allow any bacteria that may be in it to circulate in the air. Some people may buy sputum pots with lids – please use the lids and throw pots away regularly. Some people may cough into tissues which should be placed into a bin with a lid and emptied regularly. Please do not cough into a toilet or sink – or in the outside air as that can lead to aerosols and reinfection. Hands should be washed afterwards. Swallowing sputum may not be a good idea as there is evidence that stomach acid does not always destroy NTM.
Order of treatment
This allows for optimal clearance and to allow medications to take maximal effect. If you have not been prescribed items on the list below, move to the section ‘know your chest’.
Reliever inhalers / nebulisers e.g. Salbutamol / Ipratropium.
Wait 10-15 minutes if possible.
Sputum thinning nebulisers e.g. hypertonic saline
Chest clearance
Long acting inhalers (there are many different types of long acting individual or combined inhalers but typically these would be taken once or twice per day. If unsure check with your pharmacist)
Nebulised / Inhaled antibiotics
Know your chest
It is good to know what is normal for you. How breathless are you doing daily activities? What colour is your sputum? How thick is it? How much do you produce daily? How wheezy or tight are you? What is your normal temperature? (measure it twice per day for a week). If you know what is normal for you then you can spot changes from normal that may be the early signs of a chest infection. If you can identify an infection early, it can be treated before you become too unwell.
Types of chest clearance
There are several different ways for you to clear your chest, some involve breathing exercises, and some involve the use of OPEP devices (oscillating positive airways pressure) (see links at the end of this webpage). There is no strong evidence to suggest one technique is better than another so you need to find a technique that is effective for you and which you can incorporate into your day-to-day routine. Some of the techniques are unsuitable for some people with other conditions. We will list these with the techniques but suggest trying the breathing exercises first as these may be effective for you without the need for a device,
Breathing techniques
*Avoid huffing if you have coughed up blood within the last 48hours.*
There are 3 parts of this which have fancy names, try not to get bogged down by the names rather focus on what you need to do…
This is gentle and safe to use even of you are coughing up some blood.
It involves breathing at different volumes and works by moving sputum from the smallest airways to the bigger ones like squeezing toothpaste along a toothpaste tube.
Postural drainage may not be helpful as a chest clearance on its own. It is most effective when used in conjunction with other types of airway clearance such as the breathing exercises or OPEP devices.
Many people with a lung condition are fearful of exercise and see getting short of breath when exercising as bad or even dangerous. Getting breathless is a normal response to your body working a little harder than usual…
There are a number of devices that can be used to aid chest clearance. The ones we will discuss are the Acapella, the Aerobika and the Flutter. These are all OPEP devices (oscillating positive airways pressure) they work by providing a little resistance as you blow into them and vibrating at the same time which holds your airways open and helps shake the sputum off your airway walls.